Spring AGAWAM SOCCER ASSOCIATION
Fall REGISTRATION FORM
WWW.AGAWAMSOCCER.ORG
In –Town Rec. League OR Pioneer Valley Travel Team Male Female
Player Name: Date of Birth: / /
Address: City: State: MA Zip:
Home Phone #: - - Parent’s Cell Phone #: - -
E-Mail Address:
GRADE AGE GROUP
Uniform Size: Grade during the soccer
Please specify youth or adult sizing. season
Has your child played soccer before? Yes No
Has your child played goalie before? Yes No
If yes, what age group: Do not write in
this box, ASA
Last season coach or
staff only
team name or color:
REGISTRATION FEES:
Received by:
Pre-K $75
Kindergarten $75
In-Town U-7 & Above $85 Cash or Check #:
Pioneer Valley Travel Team $115
Amount Paid
To be filled out by ASA Staff
Please makes checks payable to: AGAWAM SOCCER ASSOCIATION
MEDICAL INFORMATION AND WAIVER OF INJURY: (Please include name & phone # when possible)
Medical Problems:
Person to Notify in Emergency: Cell Phone #: - -
I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the USYSA, its affiliated organizations and
sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the registrant for its soccer
program and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their
employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on the behalf of the
registrant as a result of the registrant’s participation in the Program and/or being transported to or from the same, which transportation I hereby authorize.
I also understand that an injury to my child in league practice or during a game is my responsibility and that the Town of Agawam Park and Recreation
Department, whose facilities are used, and the Agawam Soccer Association, and its coaches and members, are hereby released from liability.
Consent for Medical Treatment (minor)
As Parent or legal guardian of the above-named player, I hereby give my consent for emergency medical care prescribed by a duly licensed
Doctor or Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well-being
of my dependent
Signature: Parent’s Name:
Address: City: State: Zip:
Home Phone #: - - Business Phone #: - -
Cell Phone #: - - Today’s Date: / /
I would like to help: COACH ASST. COACH RIVERSIDE TOURNAMENT JAMBOREE